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-PAN MVAVVM YVVN3 t rwOWV n-&N., .Ln•.V..Y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P Q„.,C 388, 445 N. SAN JOAQUIN ST., STOCKTON, 6201.388 <br /> (709) 458.3470 <br /> NON—REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete In Triplleate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described, This application is <br /> made in compliance with San Joaquin county Development Titte, Chapter 9.1115.3 and the Standards of Son oequin County Public Health <br /> Services, Environmental <br /> Health Division. <br /> - <br /> PoRthLQA3\ NO , 9 city Address/or APN# _ I—O C_^_- J_`N_ <br /> _ Parcel Size/APN# <br /> Owner's Name �b l32l;��`�n� Address <br /> ft r V Phone <br /> U PhoneContractor.SkL� `�fEe ��( Address p N CY L 1#� <br /> � <br /> � Qld^638 <br /> 7?-7(oSub Contractor ," ILlU �ddress :, C-&Lu)8cAic# Phone <br /> TYPE OF WELLJPUMP: NEW WELL iJ REPLACEMENT WELL -NON <br /> ITORING WELL # ❑ OTHER <br /> 11 DESTRUCTION [I OUT-OF-SERVICE WELL "El GEOPHYSICAL WELL #� LI SOIL BORING <br /> IL.'NSTALLATION [I WELL SYSTEM REPAIR LI CROSS-CONNECT REPAIR [l VAPOR EXTRACTION WELL S <br /> New L] Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WEIL CONSTRUCTION SPECIFICATIONS <br /> LI INDUSTRIAL 13 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA, OF CONDu TOR CASING <br /> (I DOMESTIC/PRIVATE [) GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC �(/L' DIA. OF WELL �ASiNG �- <br /> (I PUBLIC/MUNICIPAL LI DRIVEN DEPTH OF GROUT SEAL �/ SPECIFICATION 5C11' fl"o 7�/e <br /> 0 IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY Li/e..-6! c,m.s7GROUT BRAND N /c/U1111201"Lcs4 <br /> Pd—MON <br /> 1TORiNG GROUT SEAL PUMPED: 0 Yes Y NO CONCRETE PEDE TAL BY DRILLER:09-yes 11 No <br /> APPROX.DEPTH 0 � LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRIIIING METHOD, MUD ROTARY,_ AIR ROTARY_ AUGER CABLE OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with $ n Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signatur4 certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shat( not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: w 1 certify that in the performance <br /> of the work for which this permit is issued, i shall employ persons subject to WORKMAN'S COMPENSATION Laws 0 California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIREQ INSPECTIONS AT(2091488.8423. Complete drawing at tower area p ovided. <br /> Signed X Titles' z<N A��67Datol / 6 <br /> C1122 <br /> DEPARTMENT USE ONLY q <br /> Application Accepted 8y Date Zi,O 6 Area <br /> Grout Inspection By Date puivp Inspection By Date <br /> Destruction inspection fay Date Comments: , s r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY PATE PERIAt7iSERY10E RE OU T NUMBER INVOICE <br /> t o v o o io 4 <br /> ?-O'ci L6 T 22269 T G T Cil WOd=l I4dZ0:T T b66 T-9Z-22 <br />